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Introduction
All children and adolescents encounter routine setbacks and disappointments that can cause them to feel sad and, listless, and to lose interest in school and other activities. Although most youth are able to manage these episodes with minimal interference to their lives, 2-5% experience depressive symptoms that are severe enough to significantly affect their academic, social, and emotional development and, result in the diagnosis of a depressive disorder such as Major Depressive Disorder or Dysthymic Disorder. Untreated depression can lead to additional psychological difficulties such as substance abuse, self-injurious behaviors, and even suicide.
Depressive Disorders in Youth
Major Depressive Disorder
Sadness following a loss or major setback is a natural and normal part of child development; however, for some youth their sadness and other related symptoms are severe enough that they may meet criteria for Major Depressive Disorder. Depression can contribute to poor academic performance, loss of important relationships, and failure to participate in developmentally appropriate activities. Depression in children often includes irritability and physical complaints, such as stomachaches or headaches. Depressed adolescents typically report the same symptoms as adults. The typical signs of Major Depressive Disorder include the following symptoms, which must be present for at least two weeks:
- Sadness;
- Hopelessness (feeling that "nothing will ever work out for me");
Irritability and crankiness and the feeling that others are to blame for the youth's mistakes;
- Physical symptoms or health complaints such as stomachaches, headaches, or other aches and pains;
- Loss of interest in or enjoyment from friendships, sports, music, and other activities the child used to enjoy;
- Skipping meals or picking at food that results in failure to gain expected weight or weight loss, or overeating or bingeing on junk food that results in weight gain;
- Trouble sleeping that results in napping, falling asleep in class, or low energy;
- Poor concentration and memory leading to a decline in grades and/or athletic performance;
- Feelings of worthlessness or inferiority;
- Talking about harming or killing oneself and/or taking actions such as cutting and burning one's body.
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Dysthymic Disorder
Changes in friendships or the transition from elementary to middle school or from middle school to high school, may cause a youth to experience fatigue, irritability, changes in sleep, and low mood. Although these symptoms may last for several weeks or months, most youths eventually adapt to these life changes and their mood brightens. However, for some youth these symptoms persist and the low mood becomes chronic; when this happens, the youth may meet criteria for a diagnosis of Dysthymic Disorder. Unfortunately, Dysthmic Disorder can go unnoticed, as the youth's symptoms may not greatly interfere with daily functioning. However, the subtle erosion of mood and self-esteem is quite damaging, limiting the youth's ability to try new activities, pursue relationships, and actively engage in academic and athletic interests. The typical signs of Dysthymic Disorder include these symptoms, which must be present most days for a year or more:
- Feeling sad, blue, or cranky, as if the glass is always half empty;
Skipping meals or picking at food, poor appetite, or bingeing on junk food or routinely overeating;
- Trouble falling asleep due to thinking about the bad things that happened that day, or nighttime waking, napping, and teacher reports of child falling asleep in class;
- Low energy and general sense of sluggishness;
- Difficulties in concentration and memory that result in poor academic performance and lowered grades;
- Feeling worthless and inferior, and believing that things will never get better.
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Cognitive-behavioral model of depression in youth
Depression in youth is multi-determined, influenced by cognitions, interpersonal interactions, genetics, and stressors. The cognitive-behavioral model of depression in youth emphasizes the interactive effects of emotions, behavior, and cognition within the context of child and adolescent development. The model asserts that low mood and depression are created and maintained by negative thinking and problematic behaviors. For example, in response to the break-up of her first romantic relationship, an important milestone in adolescent development, a 14 year-old girl thinks, "I'm ugly and no-one will ever love me," causing her to feel extreme sadness that she tries to control by cutting her arm or by retreating to her room and failing to return her friends' calls. After a time her friends stop calling her which, in her mind, further supports her belief that she is ugly and unlovable, further intensifying her depressed mood. This downward spiral of depression can result in suicide attempts or other self-destructive acts.
Cognitive behavior therapy for depression in youth
Cognitive behavior therapy (CBT) for youth is an evidenced-based treatment approach that focuses on teaching the youth a set of concrete skills to manage his or her depressed mood. Core components include:
- The therapist educates the youth about depression and other negative emotions that affect the youth's life, as well as highlighting the interactions among behaviors, thoughts, beliefs, and attitudes that can trigger and maintain depression.
- The youth learns to monitor mood, thoughts, and behaviors in order to increase his or her awareness of the triggers of depressed mood. Increased awareness helps the youth recognize early signs of a coming depressive episode as well as the cognitive and behavioral components that contribute to the maintenance of the depressed mood. With awareness, the youth can better manage his or her mood through the use of other coping strategies learned in CBT.
- The youth and therapist work together to schedule pleasant activities to counter the youth's tendency to isolate or withdraw from activities that could improve his or her mood.
- The therapist teaches the youth alternative and more adaptive ways of thinking to decrease hopelessness and improve mood.
- The therapist teaches concrete skills to help the youth solve everyday problems that can lead to depressed mood and suicidal urges.
- The therapist teaches verbal and non-verbal skills to help the youth more effectively achieve his or her own goals in relationships, with family members, peers, teachers, and other important people in the youth's life.
- The therapist teaches the youth skills to ensure the youth can manage his or her mood after treatment has ended.
Treatment components are selected based on the youth's needs, interests, and developmental level. Parents are an integral part of treatment and are taught many of the same skills the youth learns so they can assist the youth to manage his or her mood, as well as to improve the quality of their parent-child relationship, which may have suffered as a consequence of months or years of depression.
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